Provider Demographics
NPI:1922822469
Name:JOHNSON, JEANINE LYNN CAMPBELL (TLLP)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:LYNN CAMPBELL
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1092 BEACONSFIELD AVE APT 2S
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-2014
Mailing Address - Country:US
Mailing Address - Phone:425-894-6978
Mailing Address - Fax:
Practice Address - Street 1:5229 CASS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3930
Practice Address - Country:US
Practice Address - Phone:313-577-2840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6352000958103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical